Author: Alan J. Card, PhD, MPH
Evidence-Based Health Solutions, LLC
Beyond Performance Management
The pandemic of avoidable patient harm may be the leading cause of death in many countries. But, rather than treating this as a public health crisis, policy makers around the world have largely treated it as a performance management issue. Responsibility for improvement is left to individual healthcare organizations and healthcare workers.
That approach might be reasonable if there were a strong evidence base for how to improve patient safety, and all that was required was to implement it. But healthcare organizations today face just the opposite. Despite a handful of bright spots, (1, 2) the vast majority of patient safety practice is not evidence-based (3, 4, 5) - and does not appear to be effective in reducing the rate of patient harm. (6)
A Public Health Crisis
In the US, where the modern patient safety movement was born, heart disease kills over 600,000 people each year, and is listed as the leading cause of death. (7) But this number, while vast, is almost certainly surpassed by the death toll from avoidable patient harm. (8)
An estimated 440,000 people die of preventable harm each year in US hospitals, alone. (9) This is more than 1200 people per day. But it represents only a fraction of the deaths caused by avoidable patient harm, because hospitals are only one component of the broader healthcare system.
Based on paid malpractice claims, harm from outpatient care may be just as high. (10) Throw in long-term care, home health care, community pharmacies, and behavioral health care, and there is little doubt that avoidable patient harm is the leading cause of death in the US today. (8)
And death is not the only important measure. The rate of so-called serious harm (which results in permanent disability, extended hospital stays, death, or a requirement for life-sustaining intervention) is estimated to be 10-20 times higher. In the US each year, somewhere between 4-8 million people suffer avoidable serious harm in hospitals alone. (9)
But the pandemic of patient harm is not being treated like the public health crisis it is. National governments and other funders spend far less on research to combat patient harm than they do on other public health issues like heart disease or cancer. As a result, not only have we failed to make much progress toward safer care, (6) but we also can't even quantify the problem.
Many countries track hospital-acquired infections using standardized and validated measures, just as they would for any other reportable infectious disease. But beyond that? There is almost no routine epidemiological surveillance of patient harm that would pass muster in the public health community.
It is well past time to bring the full public health arsenal to bear on the problem of patient harm.
Public Health Solutions
What would it take to start treating patient harm as a public health crisis, rather than a performance management problem?
Here are a few recommendations:
1. National public health authorities should broaden their participation in patient safety beyond hospital-acquired infections. They should develop and deploy validated data collection instruments to measure important forms of patient harm, and the risk factors that lead to such harm.
2. Patient harm, and the risk factors for such harm, should face at least the same level of regulatory scrutiny as occupational harm and its risk factors.
3. Government research agencies and other funders should invest in patient safety research at a level that is consistent with the population health burden imposed by avoidable patient harm. In wealthy nations, this means that patient safety research should receive funding of the same magnitude as that spent on heart disease and cancer.
4. Schools and programs in public health should develop curricula in patient safety, and should encourage interdisciplinary research in the field. All the core disciplines of public health are applicable to the problem of patient harm, and all should be invited to the table. (8)
5. Patient safety practitioners should consider public health training as a route for professional development. A foundation in the multidisciplinary science and practice of public health can improve capacity in key areas such as:
-Uncovering the systemic causes and contributing factors of patient harm
-Measuring harm at the patient population level
-Ensuring that safe care is equally available to all patient populations
-Designing effective interventions in a multi-stakeholder environment
-Managing change in complex adaptive systems. (8)
Acknowledgements: This blog post is based in part on the article "Patient Safety: This is Public Health," which was published in the Journal of Healthcare Risk Management.
1. Pronovost P, Needham D. An intervention to decrease catheter-related bloodstream infections in the ICU. NEJM 2006;355:2725–32. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa061115
2. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. NEJM 2009;360:491–9. Available from: http://www.nejm.org/doi/full/10.1056/NEJMsa0810119
3. Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff 2005;24:138–50. Available from: http://content.healthaffairs.org/content/24/1/138.long
4. Shekelle P, Pronovost P, et al. Advancing the Science of Patient Safety. Ann Intern Med 2011;154:693–6. Available from: http://annals.org/article.aspx?articleid=474759
5. Card AJ, Ward JR, Clarkson PJ. Getting to Zero: Evidence-based healthcare risk management is key. J Healthc Risk Manag 2012;32:20–7. Available from: http://onlinelibrary.wiley.com/doi/10.1002/jhrm.21091/abstract
6. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. NEJM 2010;363:2124–34. Available from: http://www.nejm.org/doi/full/10.1056/NEJMsa1004404
7. CDC. FastStats: Leading Causes of Death. 2015. Available from: http://www.webcitation.org/6YTVlubW9 (accessed 12 May 2015).
8. Card AJ. Patient Safety: This is Public Health. J Healthc Risk Manag 2014;34:6–12. Available from: http://onlinelibrary.wiley.com/doi/10.1002/jhrm.21145/abstract
9. James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. J Patient Saf 2013;9:122–8. Available from: http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx
10. Bishop TF, Ryan AM, Ryan AK, et al. Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA 2011;305:2427–31. Available from: Available from: http://jama.jamanetwork.com/article.aspx?articleid=900983
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